Provider Demographics
NPI:1174757314
Name:WYLIE, CASEY REED
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:REED
Last Name:WYLIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 PEPPERS FERRY RD NW
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073-5798
Mailing Address - Country:US
Mailing Address - Phone:540-808-8537
Mailing Address - Fax:
Practice Address - Street 1:1504 SPRINGHILL AVE
Practice Address - Street 2:ROOM 3414
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-3207
Practice Address - Country:US
Practice Address - Phone:251-434-3480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-02
Last Update Date:2009-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program